A renewed onslaught of bombing in Syria’s besieged Eastern Ghouta enclave has wreaked havoc in the region, killing nearly 200 people in a matter of days and shattering cease-fire negotiations.

Forces loyal to Syrian President Bashar Assad have pummeled rebel-held Eastern Ghouta with relentless shelling and airstrikes this week, in defiance of international human rights laws. Assad’s Russian-backed regime has repeatedly been accused of committing war crimes and crimes against humanity, including the use of chemical weapons against civilians, throughout the country’s nearly seven-year war.

“The situation in East Ghouta is worse than it has ever been,” theSyrian American Medical Societysaid in a news release. “The humanitarian situation is appalling, and [it] is worsening every day.”

At least 75 people were killed on Thursday alone, including 15 children, SAMS reported. The United Nations has been unable to deliver aid to the dilapidated Damascus suburb since November, and many of its 400,000 residents havetaken desperate measures to survive as food and medical supplies rapidly dwindle.

Urgent medical evacuationsbegan to trickle out of the area in December, and Russia agreed to a cease-fire in late January ― but regime airstrikes quickly doused fragile hopes of a lasting end to the violence.

Youth in Eastern Ghouta “are being starved, bombed and trapped,” said Sonia Khush,Save the Children’s Syria response director. “Children and teachers are terrified that at any moment they could be hit. The siege means there is nowhere for them to escape.”

Hundreds of children are in urgent need of medical evacuation, according toUNICEF Executive Director Henrietta Fore.

“Four years of siege have crumbled health and other basic services critical to children’s survival and growth,” she said Thursday. “For children who remain trapped under siege and under wanton, heavy violence across Syria, life is a living nightmare. They are struggling just to stay alive.”

Schools and hospitalshave been targetedin the attacks, demolishing much of the region’s remaining infrastructure and discouraging people from seeking desperately needed medical care. There is currentlyless than one doctorper thousand people in Eastern Ghouta, which now has the war-torn nation’s highest rate of malnutrition.

“I would like to confirm that all the fatalities and the injured are civilians. The reason is that the air raids target only the markets and the residential neighborhoods,” said a SAMS medical worker.

For Assad, encircling Syrian territory and populations is a way to exert control while defying those who oppose his leadership. He has kept the enclave under siege since 2013, shortly after a sarin gas attack by regime forces killed an estimated 1,429 people there.